Sexual violence against men in Brazil: underreporting, prevalence, and associated factors

ABSTRACT OBJECTIVES Identifying and mapping the literature regarding sexual violence against Brazilian boys and men, as well as describing its underreporting, prevalence, and associated factors. METHODS We conducted a scoping review by searching PubMed, Biblioteca Digital Brasileira de Teses e Dissertações, Biblioteca Virtual em Saúde, Scopus, and Web of Science databases. The inclusion criteria were: (a) surveys including data on sexual violence; (b) inclusion of boys or men as victims of sexual violence; (c) presenting statistical data on prevalence, underreporting, and factors associated with sexual violence among Brazilian boys and men. RESULTS We found a total of 1,481 papers. Ultimately, 53 were included and had their data extracted. Most studies are quantitative in nature (n = 48). The total number of participants across studies was 1,416,480 and the prevalence of sexual violence ranged from 0.1% to 71%. It is important to note that underreporting statistical data was cited in several studies. The group with the highest prevalences was men who have sex with men and those with sexual dysfunctions. Increased tendency to drug use, social isolation, unprotected anal sex, suicidal ideation, sexual dysfunction, and post-traumatic stress disorder were statistically significant predictors for having experienced sexual violence. CONCLUSIONS Despite the prevalence of sexual violence being high against Brazilian boys and men, this area of is surprisingly understudied and there are few studies with this exclusive scope. Social cultural issues, such as sexism, contribute to the underreporting of sexual violence. Additionally, we identified issues related to mental, sexual and reproductive health to be associated with sexual violence. Based on our findings, we recommend the implementation and development of a structural infrastructure aimed at supporting boys and men who are victims of sexual violence, and preventing negative outcomes for this affected group.


INTRODUCTION
Sexual violence against boys and men is often neglected by various social sectors, resulting in an evidence gap around the topic1 ,2 . The available information on sexual violence is mostly related to female victims, especially female children and adolescents 3 .
From an analysis of the notification data from the Sistema de Informação de Agravos de Notificação (Sinan), between 2009 and 2013, it was possible to observe an increase in notifications of 291.92% of sexual violence against boys and men. In 2013, cases against this population accounted for 12.58% of all reported cases 4 . Data from an epidemiological bulletin from the Ministry of Health, between 2011 and 2017, show that the proportion of total notifications of this kind of violence against male children was 25.8% and against adolescents, 7.6% 5 .
The Brazilian Public Security Forum, a non-governmental organization (NGO), systematizes, through the Public Security Yearbook, all occurrences registered in the police stations and reported to the State Public Security Secretariats. According to the analysis of this data, published in 2019, sexual violence against boys and men accounted for 14.3% of all cases reported to the police 6 . Disque Direitos Humanos, in turn, reported in an annual report, also published in 2019, 18% of all reported cases 7 .
A review of the sexual violence literature in Brazil identified a range of prevalence among men from 1% to 35% 8 . According to the author, although the variation is large, the included studies indicate a higher occurrence than presented in the official statistics of the reporting systems. Among the 40 papers included in this review, only 14 included data on the prevalence of this violence in the male population.
In an analysis of the Public Security Yearbook data, the authors state that sexual crimes are among the least reported, which can be attributed to factors such as fear of the aggressor, judgments, or guilt 9 . A study conducted with men and women from a representative sample of the urban population of São Paulo concluded that experiences of sexual violence are more difficult to report when compared to other aggressions 10 . However, because of the way men are raised in a patriarchal society, it may be more difficult for them to talk about victimization experiences, producing a major problem in the reporting of rapes against men and boys 2 .
Aside from the prevalence of sexual violence against men in Brazil being often neglected and under-reported when compared to the violence suffered by women, the characteristics of these rapes are also worthy of further investigation. In this sense, this paper aims to identify and map in the scientific literature the studies dealing with sexual violence against Brazilian boys and men in the period between 2015 and 2020, seeking to obtain data on prevalence, underreporting, and factors associated with sexual violence.

METHODS
We developed a scoping review, according to the methodology proposed by the Joanna Briggs Institute 11 . Scoping review is a form of evidence synthesis that employs a systematic method to map all scientific literature on a given subject, such as key concepts, study characteristics, specific data according to the study objectives, and evidence gaps 12 .

Search Process
To construct the research question, the acronym PCC was used: population (boys aged 0 to 18 years and men, over 18 years), concept (victims of sexual violence) and context (studies conducted with Brazilian boys or men) 13 , resulting in the research question: "What are the data on underreporting, prevalence and factors associated with sexual violence against Brazilian boys and men published between 2015 and 2020?".
Searches were conducted on July 27, 2020, in the PubMed, Biblioteca Digital Brasileira de Teses e Dissertações (BDTD), Biblioteca Virtual em Saúde (BVS), Scopus and Web of Science databases, and in all of them using the following descriptors: Sexual Violence OR Violência Sexual OR Abuso Sexual OR Sexual Abuse OR Boys AND Men OR Meninos OR Homens AND Brazil OR Brasil.

Inclusion and Exclusion Criteria
The type of studies selected to conduct this review included peer-reviewed articles, dissertations, and theses. The inclusion criteria were: (a) surveys including data on sexual violence; (b) inclusion of boys or men as victims of sexual violence; (c) presenting data on prevalence, underreporting, and factors associated with sexual violence among Brazilian boys and men. We excluded studies that did not present data stratified by sex, that did not have men as victims, that did not include Brazilian boys or men as victims, and that focused on other forms of violence.

Data Screening and Extraction
The database searches yielded 1,481 papers. After removing duplicates and articles that were not available, the titles and abstracts of 1,458 studies were read, of which 1,371 were excluded because they did not match the inclusion criteria. In total, 87 texts were read in their entirety for eligibility, of which 34 were excluded: nine for not presenting data stratified by sex, nine in which men appeared only as sexual aggressors and not as victims, eight for not presenting data on Brazilian men, and eight for presenting forms of violence other than sexual (supplementary table a ). In total, 53 papers were included in this review.
The data from the included articles were populated in a spreadsheet including: year of publication; location; type of publication; authors' names; type of design; study objective; participants; data collection method; main findings; and prevalence of sexual violence.
Figure presents the flow chart of study selection and eligibility. The selection, eligibility, and extraction processes were performed by one researcher (DFG) and checked by another researcher (PPM).
As is the practice in scoping reviews, the results will be presented starting with the characteristics of the studies and then presenting the main findings regarding the study objectives.

RESULTS
A total of 53 studies were included, most of them quantitative in approach (n = 48), 38 cross-sectional studies  , one exploratory descriptive 51 , three longitudinal 52-54 , one observational time-series 4 and one case series 55 . The remaining papers consisted of: four qualitative 56-59 , two literature reviews 8,20 , two intervention studies 61,62 and one case study 63 . Among the 53 papers reviewed, 13 were conducted with secondary data 4,28,30,[39][40][41]44,48,51,52,55,58,64 . The total number of participants was 2,831,581, of which 1,416,480 were boys or men. The research with the smallest sample size was a case study (n = 1) and the one with the largest was a study that used data from the 2015 National School Health Survey (n = 1,248,581).
The sampling techniques of the selected papers include representative population samples 10 birth cohort 54,53 and multistage conglomerate survey 49 . Eight other studies did not collect primary data, using secondary data or testimony from other research 16,23,28,30,31,48,51,59 .
Of the studies on factors associated with violence, only 14 focused on sexual violence as the main objective and, based on this, identified the factors associated with it 18  Among these papers, which focused on sexual violence and associated factors, only two exclusively discussed violence against boys and men 27,45 .
The papers included in the category "understanding the phenomenon of sexual violence against boys and men and its impacts" were studies conducted to explain the dynamics of sexual violence and its impacts. Mostly, these studies do not describe the characteristics of the victim, the aggressor, the type of violence, and the frequency. Of these surveys, only nine considered exclusively boys and men [37][38][39]51,[57][58][59]61,63 .

Ways to Identify Sexual Violence
A number of ways to identify sexual violence have been used, ranging from surveys that included questions about forced sex to instruments validated for this purpose. Among the 53 studies reviewed, only 27 reported how they investigated the presence of sexual violence. Most asked whether participants had ever been victims of forced sex in their lives (n = 11) 14,15,17,18,22,26,29,31,45,46 . Nine studies used validated instruments, such as: Assessment of childhood trauma 35 , Sexual Experiences Survey (SES-SFV) 42 , Student Alienation and Trauma Survey -R (SATS-R), Adverse childhood experiences (ACE) 50 , National Institute of Child Health and Human Development (NICHD) 57 and Childhood Trauma Questionnaire (CTQ) 43,54 . Some studies used secondary data, mostly information from medical records of victims of sexual violence, thus they do not include screening questions.

Participants
Most of the studies in this review did not include exclusively boys or men (n = 36

Underreporting
Underreporting of sexual violence against boys and men has been a topic discussed in several papers. For the authors, the reasons that could explain the problem are: the inability of men to perceive themselves in the place of victim and confusion regarding sexual orientation, caused by the fact that most sexual assaults are provoked by other men 1,2,30,37,51,57,59 , the macho culture 1,2,51,58,59 , the greater difficulty of talking about sexual violence when compared to other forms of aggression 10 , the lack of training of the agents involved in the notification process 37 , the fear of reproduction of the abuse, of the parents' reaction, of a family breakdown, and the fear of the aggressor's reactions due to his threats 37 .
Since part of the work was based on secondary data, there are also questions about the accuracy of data recording. These data recording problems range from filling out errors 31 to missing important information, namely, the sex of the victim and the offender 51 .

Prevalence of Sexual Violence
Most of the studies included in this review present data on prevalence of sexual violence (n = 36). Among the 17 studies conducted exclusively with boys or men, only eight present this information 15,16,26,27,34,38,45,50 .
The lowest prevalence described was 0.1% in a study carried out with a representative sample of the urban population of the city of São Paulo, which counted on information from 5,037 people, of whom 2,187 were men 10 . The highest prevalence, on the other hand, was 71%, presented in a study also carried out in São Paulo with 80 men who presented complaints of sexual dysfunctions seen at a specialized service 27 .
The variation in the prevalence data presented from Table 1 can be explained by the way the participants were selected, as well as the manner in which they were asked about their experience of sexual violence. Broader questions, such as about sexual experience before age 13 with someone five years older or more, may reveal a higher prevalence (59%) 16 and narrower or more specific questions may produce lower response rates in participants.
In the survey with men with sexual dysfunctions, when asked about rape or attempted rape (sex with penetration) the prevalence was 10%; however, when these same men were asked about any non-consensual sexual experience before the age of 12, the prevalence increased to 71.3% 27 .
The research that investigated sexual assaults in nightclubs in São Paulo was one of the few to include male and female people, and the prevalence of sexual violence was higher among men: 1.4% of men and 0.7% of women reported attempted rape; regarding sexual assault, the numbers were 11.7% and 11.1%, respectively 19 . Another study in which the prevalence of sexual violence was higher among boys was conducted among adolescents of both sexes, students in the second year of high school in ten Brazilian capitals. In this study, the prevalence among boys was 12.5% 49 . In the others, with people of both sexes, the prevalence of sexual violence was higher among girls and women 8,20,46,53 , as well as in the studies in which risk was estimated: girls and women were identified at higher risk of being raped than men 18,54 .

Characteristics of Sexual Violence
Only 23 papers present information that identified the aggressor, most of them people known to the victims. Violence perpetrated by the father or stepfather was common in eight studies 22,30,31,39,46,48,58,59 . Authors who have not described who the perpetrators are point to known and/or familiar figures 4,26,27,51,57,65 . There are also studies that describe violence committed by intimate partners 8,23,38,50 . It is noteworthy that women appeared in six studies as sexual rapists 28,36,39,46,51,58 .

Factors Associated with Sexual Violence
Several factors have been described to be associated with sexual violence. Negative mental health outcomes were the most frequently cited, including: post-traumatic stress disorder (PTSD) 25,66 ; suicidal ideation 29 ; drug use and social isolation 17,22,67 ; and psychosis 63 . In addition to mental health issues, having unprotected anal sex 15,26 and sexual dysfunction 27 were also related to sexual violence.
Other forms of violence were associated with sexual violence, among them: abuse in childhood and physical violence 32 ; discrimination due to sexual orientation 26 ; intimate partner violence 34 ; rape in adulthood 18 . In a study that analyzed the victims' records, it was possible to identify that the duration and severity of the abuse were associated with the sexual violence suffered by boys 30 . Table 1 describes the main characteristics of the studies.

DISCUSSION
Our study indicates a lack of research that exclusively studies sexual violence perpetrated against the adult or child male population. We also identified the underreporting of this kind of violence, an aspect cited in several studies, which may have causes in cultural norms, making it difficult for boys and men to perceive themselves as victims or even to talk about experiences that may indicate some fragility. However, prevalence studies show that sexual violence against this part of the population is a problem of great magnitude, with a significant variety of associated factors, such as negative mental health outcomes, behavioral or socialization problems, and clinical issues. Few studies had representative samples and the nature of the screening questions profoundly influenced the variation in estimated prevalences. In the surveys in which people of both genders were included, the prevalence was higher for females, corroborating the results of other studies that point to women and girls as the main victims of sexual violence 8,12,68 .
According to a study conducted in 2013 by the Institute for Applied Economic Research (IPEA), only 10% of cases of sexual violence are notified 69  Underreporting is a problem in many ways, but the fact that boys are not able to talk about their sexual trauma until much later may be associated with more severe and longer-lasting abuse 30 . In a study carried out with surveillance data, sexual violence against men and boys happened earlier when compared to girls, and the explanation for this phenomenon lies in the incapacity of the younger child to recognize the situation as violating and to break the silence 28 . This becomes even more difficult when one considers the sociocultural expectation that men are strong and resilient, generating a possible constraint for those who suffer sexual violence 6,20 .
Although there is a major problem regarding the underreporting of sexual violence against men, the prevalence data described in the studies range from 0.1% to 71%. Men who have sex with men, men with sexual dysfunctions, and drug users had higher prevalences than the other groups. In a population-based study with a representative sample from the USA, researchers found that bisexual and homosexual men were more likely to have a history of childhood sexual violence than heterosexual men 70 . Another aspect identified in the studies that make up this review is that most of them were about children and adolescents or investigated aggression in childhood. Only three studies investigated violence in adulthood, indicating a gap in evidence on sexual violence against adult men.
The National Health Survey (PNS), conducted for the second time in 2019, included questions to screen for sexual violence and pointed out that 2.5% of men aged 18 years or older participating in the survey had experienced sexual violence once in their lifetime, which represents approximately two million men 71 . In a literature review on the prevalence of sexual violence and its characteristics, the author identified prevalence ranging from 1% to 35% among males, but only 35% of the papers included in the review contained information on male victims. This corroborates the need for more studies on Brazilian men who suffer or have suffered sexual violence 2 .
The definition of sexual violence adopted by the researchers changed the prevalence results. Studies investigating all forms of sexual violence found higher prevalences; studies with more specific questions, on the other hand, showed lower prevalences. We find it difficult to choose a screening question that can be used widely, but we see the need for debate around this issue.
Regarding the factors associated with sexual violence against men and boys, this review points to a diversity of outcomes, from negative mental health outcomes (PTSD, drug use and abuse, suicidal ideation) 25,66 to clinical problems (erectile dysfunction and premature ejaculation, and chronic pelvic pain) 27 and behavioral issues (frequent HIV testing, unprotected anal sex, social isolation, and commercial sex) 15,17,22,26,67 . Several studies also indicate the presence of suicidal thoughts, social isolation, sexually transmitted infections (STIs), guilt, low self-esteem, psychosomatic illnesses, and physical and emotional development problems in victims 2,26,[72][73][74] . In this sense, our results do not differ from other studies, indicating indeed a serious public health problem.
The characteristics of the violence, such as the sex of the aggressor and the place where the violence happened, were one of the points less explored by the researchers, and even so, the results indicate that in relation to the characteristics of the aggression, sexual violence suffered by men and women are similar, because the aggressors and the places have the same identifying features 8,71 .
It is important to point out that this scoping review has some limitations that should be considered when interpreting the results. Important databases were chosen to carry out the search for the studies, but it is recognized that there is a limitation in the variety of the type of material analyzed, since government documents and the proceedings of scientific events, for example, were not included.
It is not common practice in scope reviews to adopt quality assessment of the studies and statistical treatment for quantitative data, as is the case for systematic reviews. Therefore, there may be a limitation regarding the quality and scientific rigor of the studies included.

CONCLUSIONS
In the period studied, the underreporting of sexual violence against men and boys seems to be a problem of great magnitude, which can be explained from the cultural norms surrounding the male gender. The prevalence of this violence, although largely variable, is higher than the data found in the notification systems, which may indicate the problem of underreporting in the official systems. Regarding the associated factors, there is a body of data presented indicating that men victim to sexual violence may suffer a series of consequences in several areas of their lives.
In this sense, efforts are needed for the realization of future studies with representative samples, screening questions of sexual violence that capture all forms of non-consensual sexual contact, aiming to understand the violence suffered by the male population, and with primary data, avoiding any bias in filling out the notifications. It is important that future studies are able to describe the characteristics of these assaults against men and boys, such as how long they lasted and how long the victims took to talk about what happened.
In Brazil, the Specialized Reference Centers of Social Assistance (CREAS) serves children and adolescents who are victims of rights violation, but these services are mostly used by female children. We know of only one Brazilian initiative that offers psychological care for male victims of sexual violence: Memórias Masculinas. Ultimately, we suggest that public policy makers should focus on developing strategies to be more inclusive of the male experience with sexual violence, and explore methods to prevent adverse effects.